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Printer Friendly Version Screening Services and Procedures

Screening Services and Procedures

DESCRIPTION

The goals of preventive health services are to avoid the development of disease and to diagnose disease in its early stages before it results in significant morbidity. Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as:

screenings
counseling services
preventive medications

The Guide to Clinical Preventive Services is available to those who seek to ensure that their patients receive the highest quality clinical preventive services. It is an evidence-based tool to be used at the point of patient care. Findings and recommendations from the USPSTF guide are routinely used in a variety of settings to improve the preventive care that patients receive. As more information becomes available to clinicians and patients alike, AHRQ's goal is to help improve patients' health and well being, and contribute to better health outcomes overall.

These recommendations apply only to people who have no signs or symptoms of the specific disease or condition that the screening, counseling, or preventive medication targets. Recommendations address only services offered in the primary care setting or services referred by a primary care clinician. The Task Force makes recommendations to help primary care clinicians and patients decide together whether a preventive service is right for a patient’s needs.

Since 1998, through acts of the U.S. Congress, the Agency for Healthcare Research and Quality (AHRQ) has been authorized to convene the Task Force and to provide ongoing scientific, administrative, and dissemination support to the Task Force.

The letter grade linked to each recommendation reflects the magnitude of net benefit and the strength and certainty of the evidence supporting the provision of a specific preventive service. These grades translate to practice guidance for clinicians:

“A”	Strongly Recommended	The USPSTF strongly recommends that clinicians provide [the service] to eligible patients.	The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
“B”	Recommended	The USPSTF recommends that clinicians provide [the service] to eligible patients.	The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
“C”	No Recommendation	The USPSTF makes no recommendation for or against routine provision of [the service].	The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
“D”	Not Recommended	The USPSTF recommends against routinely providing [the service] to asymptomatic patients.	The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
“I”	Insufficient Evidence to Make a Recommendation	The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service].	Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

POLICY

Medically Necessary Screening

Only services/procedures (screenings, counseling services, and preventive medications) with "A" or "B" USPSTF recommendations are considered medically necessary under this policy. The following are considered medically necessary based on grade “A” or grade “B” by the USPSTF:

I. U.S. Preventive Services Task Force Adult "A" and "B" Recommendations

	Service/Procedure	USPSTF Recommendation	Coverage Guidelines/Policy
1	Breast Cancer, BRCA Testing (Ovarian Cancer): Screening	The USPSTF recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing.	Preventive Health Services
2	Breast Cancer: Screening	The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.	Healthy You! Wellness Procedures
3	Breast Cancer Preventive Medication	The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention.	Healthy You! Wellness Procedures
4	Cervical Cancer: Screening	The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.	Preventive Health Services Healthy You! Wellness Procedures
5	Colorectal Cancer: Screening	The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.	Healthy You! Wellness Procedures
6	Skin Cancer: Counseling	The USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.	Healthy You! Wellness Procedures
7	Tobacco Cessation (Smoking): Counseling and Interventions (Adults)	The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.	Preventive Health Services
8	Abdominal Aortic Aneurysm: Screening	The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.	Preventive Health Services
9	Aspirin for Primary Prevention of Cardiovascular Disease: Preventive Medication	The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage.	Preventive Health Services
10	Blood Pressure in Adults (Hypertension): Screening	The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 and older.	Healthy You! Wellness Procedures
11	Lipid Disorders in Adults (Cholesterol Abnormalities, Dyslipidemia): Screening	The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders. The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease.	Healthy You! Wellness Procedures
12	Tobacco Cessation (Smoking): Counseling and Interventions (Adults)	The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.	Preventive Health Services
13	Bacteriuria: Screening	The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later.	Preventive Health Services
14	Chlamydial Infection: Screening	The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. The USPSTF recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk.	Preventive Health Services
15	Gonorrhea: Screening	The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection	Preventive Health Services
16	Hepatitis B Virus Infection (Pregnant Women): Screening	The USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit.	Preventive Health Services
17	Human Immunodeficiency Virus (HIV) Infection: Screening	The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection.	Preventive Health Services
18	Immunizations, Adult	Centers for Disease Control and Prevention (CDC) recommendations	Healthy You! Wellness Procedures
19	Sexually Transmitted Infections: Counseling	The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs.	Preventive Health Services
20	Syphilis: Screening	The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen persons at increased risk for syphilis infection. The USPSTF strongly recommends that clinicians screen all pregnant women for syphilis infection.	Preventive Health Services
21	Syphilis (Pregnant Women): Screening	The USPSTF recommends that clinicians screen all pregnant women for syphilis infection.	Preventive Health Services
22	Alcohol Misuse (Drinking, Risky/Hazardous): Screening and Counseling	The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse (go to Clinical Considerations) by adults, including pregnant women, in primary care settings.	Preventive Health Services
23	Depression, Adult: Screening	The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.	Preventive Health Services
24	Tobacco Cessation (Smoking): Counseling and Interventions (Adults)	The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.	Preventive Health Services
25	Diabetes Mellitus: Screening	The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.	Healthy You! Wellness Procedures
26	Iron Deficiency Anemia (Anemia): Screening	The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. The U.S. Preventive Services Task Force (USPSTF) recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia	Preventive Health Services
27	Nutrition (Diet): Counseling	The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.	Healthy You! Wellness Procedures
28	Obesity in Adults: Screening and Counseling	The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.	Preventive Health Services
29	Osteoporosis: Screening	The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.	Bone Mineral Density Studies
30	Breastfeeding: Counseling	The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.	Preventive Health Services
31	Folic Acid Supplementation: Preventive Medication	The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.	Preventive Health Services
32	Rh Incompatibility: Screening	The U.S. Preventive Services Task Force (USPSTF) strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative.	Preventive Health Services

II. U.S. Preventive Services Task Force Child and Adolescent "A" and "B" Recommendations

	Service/Procedure	USPSTF Recommendation	Coverage Guidelines/Policy
1	Cervical Cancer: Screening	The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.	Preventive Health Services Healthy You! Wellness Procedures
2	Skin Cancer: Counseling	The USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.	Healthy You! Wellness Procedures
3	Chlamydial Infection: Screening	The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. The USPSTF recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk.	Preventive Health Services
4	Human Immunodeficiency Virus (HIV) Infection: Screening	The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection	Preventive Health Services
5	Sexually Transmitted Infections: Counseling	The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs.	Preventive Health Services
6	Gonococcal Ophthalmia Neonatorum: Preventive Medication	The USPSTF recommends prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum.	Preventive Health Services
7	Depression in Children and Adolescents: Screening	The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up.	Preventive Health Services
8	Smoking (Tobacco Use): Counseling (Children and Adolescents)	The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke.	Preventive Health Services
9	Dental Caries in Preschool Children: Screening	The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride.	Preventive Health Services
10	Iron Deficiency Anemia (Anemia): Screening	The U.S. Preventive Services Task Force (USPSTF) recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia.	Preventive Health Services
11	Obesity in Children and Adolescents: Screening	The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.	Preventive Health Services
12	Phenylketonuria: Screening	The USPSTF recommends screening for phenylketonuria (PKU) in newborns.	Preventive Health Services
13	Sickle Cell Disease: Screening	The U.S. Preventive Services Task Force (USPSTF) recommends screening for sickle cell disease in newborns.	Preventive Health Services
14	Hearing Loss, Newborn: Screening	The USPSTF recommends screening for hearing loss in all newborn infants.	Preventive Health Services
15	Visual Impairment in Children Ages 1-5: Screening	The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors.	Preventive Health Services

NOT MEDICALLY NECESSARY SCREENING

ALL other services/procedures performed for screening purposes are considered not medically necessary, including, but not limited to:

Basic and comprehensive metabolic panel
Female and male sex hormone tests
Antigen leukocyte cellular antibody (ALCAT) testing
Thyroid testing
Stress hormone tests (including DHEA and cortisol)
Vitamin B12 testing
Vitamin D testing
Allergy testing
Heavy metal testing
Saliva testing
Fecal testing
Molecular Diagnostic and Genetic testing
All nutritional deficiencies testing/ micronutrient testing (including vitamins, minerals, amino acids, antioxidants, carbohydrate metabolism, fatty acids and metabolites)
Enzyme testing
Cardiac screening tests
Homocysteine testing
High-sensitivity C-reactive protein (hs-CRP)
Novel lipid risk factors (i.e., apolipoprotein B, apolipoprotein A-I, apolipoprotein E, LDL subclass, HDL subclass, lipoprotein[a])
Nephelometry
Immune cell function assays
Stress cardiac imaging or coronary angiography
Radiologic examinations, including chest x-rays
Electrocardiogram [ECG] [EKG] services
Ultrasounds
Computed Tomography (CT) and Computed Tomography Angiography (CTA)
Magnetic Resonance Imaging (MRI)
Surveillance testing or imaging for cancer

POLICY EXCEPTIONS

None

POLICY GUIDELINES

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

12/01/2012: New policy added.

SOURCE(S)

U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/recommendations.htm

American Academy of Family Physicians, Summary of Recommendations for Clinical Preventive Services, October 2012. http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/CPS/rcps08-2005.Par.0001.File.tmp/SummaryOfRecommendationsForClinicalPreventiveServices.pdf

Five Things Physicians and Patients Should Question. http://choosingwisely.org/wp-content/uploads/2012/04/Five-Things.pdf. The following nine United States specialty societies representing 374,000 physicians developed lists of Five Things Physicians and Patients Should Question in recognition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures:

American Academy of Allergy, Asthma & Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology

CODE REFERENCE

Non-Covered Codes

All procedure codes filed for screening purposes that are not listed as grade a “A” or grade “B” recommendation by the USPSTF in the "Policy" section above are considered not medically necessary and not eligible for coverage.

Code Number	Description
CPT-4
	Any procedure code filed for screening purposes that is not listed as a grade "A" or grade "B" recommendation by the USPSTF
ICD-9 Procedure

ICD-9 Diagnosis

HCPCS

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